ODE.SSEO.NEO.EC.Request.01.21.2015 1

PA

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NT

/GU

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DIA

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Guardian Signing Scholarship Checks

I am the (check one)

SEC

ON

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PA

REN

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UA

RD

IAN

MIDDLE LAST

WHAT IS YOUR RELATIONSHIP TO THIS STUDENT?

FIRST MIDDLE LAST

WHAT IS YOUR RELATIONSHIP TO THIS STUDENT?

EDCHOICE SCHOLARS HIP PROGRAM

ο Natural Parent

ο Adoptive Parent ο Residential Parent

Legal Custodian Guardian of student applying for scholarship funds Student that is at least eighteen years of age

FIRST

STUDENT

IN

FOR

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TIO

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***ATTENTION EXPANSION APPLICANTS: INCOME VERIFICATION MUST BE COMPLETED TO APPLY FOR THE EDCHOICE EXPANSION SCHOLARSHIP****

INC

OM

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E-MAIL:

E-MAIL:

2015 - 2016 REQUEST FORM

By checking below you are indicating you will complete the income verification process. Please obtain the Income Verification form from the school OR from the EdChoice web site: http://education.ohio.gov/edchoice

PHYSICAL ADDRESS:

CITY, STATE,ZIP:

PHONE:

DATE OF BIRTH:

NAME:

RELATIONSHIP TO STUDENT:

DATE OF BIRTH:

PHYSICAL ADDRESS:

CITY, STATE,ZIP:

PHONE:

RELATIONSHIP TO STUDENT:

NAME:

MIDDLE LAST FIRST

ODE.SSEO.NEO.EC.Request.01.21.20152

SCHOOL

INFO

RM

AT

ION

Signature of Guardian Signing the Tuition Check: Date:

2015-2016 EDCHOICE PARENT AGREEMENT

to submit an application on my behalf for the Scholarship Programthrough the Ohio Department of Education electronic application system. I designate:

(Name of Private School)

EDCHOICE SCHOLARS HIP PROGRAM 2015 - 2016 REQUEST FORM

Public School

Charter/Community School

Private School

Home Schooled

Pre-School

Other

Name of public school district you live in (e.g., Elyria City, Mansfield City, etc.)

Name of public school building your child would be assigned to for the 2015-2016 School Year:

My student is currently attending a [check ONLY one and enter school name]:

I have supplied the chartered nonpublic school with a certified copy of the student’s birth certificate, copies of all custody/guardianship documentation for the student, and proof of my address

I have submitted only one EdChoice Scholarship application for the student.

The scholarship amount shall only be applied to the tuition of the enrolling school and I may be required to pay other fees and costs as prescribed by the policies of the school.

I will sign all scholarship checks received by the private school for my student in a timely manner. I understand that if I fail to endorse the scholarship checks to the school, I will be

responsible for paying the student’s tuition.

If I transfer my scholarship to another participating chartered nonpublic school, I will notify the school of my intent to withdraw and I will return to the original school to sign any remaining checks

I will apply for any and all financial aid or tuition discounts and adjustments made regularly available to the students attending the school in which the student is accepted for enrollment.

I will abide by the Ohio Department of Education (ODE) dispute resolution process outlined in Ohio Administrative Code Section 3301-11-14.

If I am not a low income parent or did not complete the income verificationprocess, I will be responsible for paying any difference between the scholarship amount and the tuition of thechartered nonpublic school.

I must inform ODE and the chartered nonpublic school of any change in the student’s residential address or custody status.

I will not be able to renew my child’s scholarship if; our family has moved to another city school district and our new neighborhood public school is not a designated EdChoice school, my

child fails to take each state achievement test required for his/her grade level, my child has more than twenty unexcused absences during the school year, or I fail to complete the renewal process. If my child has received an EdChoice Expansion Scholarship I must maintain Ohio residency and verify my income annually.

I have received and understand the policy handbook of the chartered nonpublic school and will abide by its provisions.

I understand that if my child’s scholarship has been awarded in error, it will be terminated immediately and I would then be responsible for paying the tuition if I decide to keep my child at the

I(parent name)

If my child receives an expansion scholarship, I will not be eligible to renew the scholarship if I move outside of the State of Ohio, OR if I do not have my income verified by scholarship staff.

private school.

The information provided in this application is true and correct.

agree to the following: